History: An inpatient discovery
Ms. A, 20, presented to the emergency room with an exacerbation of asthma due to noncompliance with medications. A review of her systems and a physical exam revealed significant bilateral shortness of breath, wheezes, and rhonchi.
A single mother who lives with her two daughters, ages 5 and 2, Ms. A is 28 weeks pregnant with her third child. After receiving albuterol nebulizers for her asthma, she was admitted to the obstetrics and gynecology floor for monitoring of maternal and fetal status. There, a nursing staff member observed her eating baby powder.
The psychiatric team evaluated Ms. A and learned that, during her first pregnancy at age 15, she grew uncomfortable with her increased weight and started purging. Standing at 5 feet, 6 inches, Ms. A weighed as much as 220 during the pregnancy; her weight fell to 170 pounds after delivery. When she presented to us she lamented, “All of my friends are still thin.”
The stress of being a single teenage mother and going to school, combined with disgust over her physical appearance, provoked her purging. She did not think purging would help her lose weight but would prevent her from gaining more even as she ate as much as she wanted.
For 11 months after the birth of her first child, she purged three to four times daily. She could eat as many as five “value meals” within 2 to 3 hours at fast-food restaurants. Eating relaxed her and made her feel comfortable, but the frequency of purging escalated to five to six times daily and the vomiting was physically exhausting, painful, and caused esophageal damage.
At age 17, Ms. A became pregnant with her second child. In the first 2 to 3 months, she continued to eat large quantities of food but purged less often (two to three times daily).
One day in the third month of this pregnancy, Ms. A watched as her mother used medicated powder on her own child, and the powder's scent stimulated within Ms. A an urge to taste it. Before long Ms. A was eating the powder regularly and had stopped purging. She recalled purging only three times during the remaining 6 months of the pregnancy. The craving for powder replaced both her desire to vomit and the need to binge on food. She returned to regular binging and purging (once or twice weekly) after her second child was born, however.
In your view, which should be addressed first, the bulimia or the obsession with baby powder? Or should both be addressed in tandem?
Commentary
This case displays a form of adult pica for baby powder, which has only been described in the literature for pediatric pica.1,2 She displays no cognitive deficits or psychological disorders (e.g., mental retardation, schizophrenia) that are commonly associated with pica.3-6 Pregnancy, which is also common in pica, did exist in this patient and may provide some physiologic or psychological insight into the patient’s disorder.7 The patient’s bulimia nervosa, however, gives an unusual twist to this case.
In the 18th century, pica was classified together with bulimia simply as an erroneous or aberrant appetite (Box 1).8 Pica has been known to occur with—and can be a symptom of—bulimia and anorexia, but it is rarely cited.8,10 As in other eating disorders, affected individuals are ashamed of their weight, body shape, and body image.13
WHAT IS PICA?
The term pica has evolved over centuries to describe the compulsive ingestion of non-nutritive substances or unusual food cravings. Its etymology stems from the Latin word for magpie (genus Pica), a bird said to pick up, carry away, and presumably eat a myriad of objects.
The word was first used in 1563 by Thomas Gale, who noted this consumption of unusual foodstuffs in pregnant women and children.8 In contemporary literature, the word “craving” is often used instead of pica to minimize social judgment toward practices that deviate from “normal.”
An estimated 20% of pregnant women are believed to have a history of pica, but the documented prevalence of these cravings may be underestimated because women often are embarrassed to disclose the behavior.9
Pica has been speculated to be a form of aggression, a result of compulsive neuroses, or a manifestation of oral fixation because of its association with thumb sucking.1 In the end, pica is a poorly understood disorder.
Scientists question the etiology of pica. Early psychiatric hypotheses focused on societal expectations of women’s outward beauty. A higher prevalence of pica has been recognized in mentally retarded persons and patients with schizophrenia.3-6
Pica is most frequently observed in children, pregnant women, and patients from a low socioeconomic background.10,11 More comprehensive studies have explored geophagia (a craving to eat chalk, clay, or dirt) in Africa and the southern United States.12